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Ann Thorac Surg 1997;64:70-72
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Influence of Bicaval Anastomoses on Late Occurrence of Atrial Arrhythmia After Heart Transplantation

Department of Cardiovascular Surgery, Christian-Albrechts-University, Kiel, Germany

Accepted for publication January 9, 1997.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
Background. The standard technique for orthotopic heart transplantation includes right and left atrial anastomoses, which potentially disturb the integrity of the donor atria. Consequently, electrophysiologic abnormalities such as atrial flutter and fibrillation may occur even late after heart transplantation.

Methods. Over a 3-year period, 39 heart transplantations were performed using a standard right atrial anastomosis (group A), and 40 were done using bicaval anastomoses (group B). In each group, data of 30 consecutive patients with a minimum follow-up of 9 months were reviewed retrospectively to assess the incidence of atrial arrhythmia after hospital discharge.

Results. Early postoperatively, there was no difference in the duration of temporary pacemaker requirement and incidence of permanent pacemaker implantation (group A, 7%; group B, 7%; not significant) between the two groups. In 12 patients in group A (40%), 16 episodes of atrial flutter and fibrillation were detected 20 to 205 days after heart transplantation. In group B, 1 patient (4%) suffered from atrial fibrillation on day 116 after the operation (p < 0.001).

Conclusions. Preservation of the integrity of the right donor atrium by construction of bicaval anastomoses results in a significantly decreased incidence of atrial flutter and fibrillation after heart transplantation when compared with the standard technique.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
During the past 15 years, heart transplantation has become an established therapy for end-stage heart failure [1]. The standard surgical technique with two atrial anastomoses, introduced by Lower and Shumway [2], is used by the majority of heart transplant centers worldwide. However, the anastomoses of the donor to the recipient's atria may alter both the size and the geometric shape of the atria, as repeatedly described by echocardiography and magnetic resonance tomography [3, 4]. As a result, tricuspid and mitral valvar regurgitation are frequently seen after heart transplantation [5]. Recently, two alternative techniques have been developed to preserve the atrial geometry: total orthotopic heart transplantation using separate pulmonary and systemic venous anastomoses, and the bicaval technique with separate bicaval anastomoses combined with standard left atrial anastomosis [6, 7]. The influence of the different operative techniques on hemodynamics has been repeatedly described [8–11]. However, disturbance of the integrity of the donor atrium may also lead to electrophysiologic abnormalities such as atrial flutter and fibrillation.

The purpose of this study was to determine the prevalence of atrial arrhythmias during the late follow-up after orthotopic heart transplantation, comparing bicaval and standard transplantation techniques.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
Patients
Between November 1991 and October 1994, 79 orthotopic heart transplantations were performed at our institution. Of these, 39 were done using the standard right atrial anastomosis (group A), and 40 were performed using bicaval anastomoses (group B). In each group, data of 30 consecutive patients, in whom a minimum follow-up of 9 months was available, were reviewed retrospectively to assess the incidence of atrial arrhythmia after hospital discharge. Recipient age and sex, pretransplantation diagnosis, pretransplantation antiarrhythmic medication (especially amiodarone), donor age and sex, duration of operation and extracorporal circulation, and ischemic times were comparable between the groups (Table 1).

	Operative Technique

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

GROUP B.
Standard left atrial anastomosis was performed using a continuous suture technique with 3-0 polypropylene. Thereafter, the pulmonary artery and aortic anastomoses were performed. Finally the caval veins were connected, using a 4-0 polypropylene running suture for the inferior vena cava and a 5-0 polypropylene interrupted suture for the superior vena cava [6].

	Immunosuppression and Rejection

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
In all patients, immunosuppressive therapy was initiated using antithymocyte globulin induction therapy and continued with a triple-drug regimen consisting of cyclosporin A, azathioprine, and prednisolone. Endomyocardial biopsy was performed weekly for the first 4 weeks. Afterwards, the intervals between the biopsies were prolonged stepwise to 3 months, taking into account previous rejection episodes. Additional biopsies always were performed when rejection was suspected clinically and at the onset of atrial arrhythmia. Rejection was graded histologically according to the classification of the International Society for Heart and Lung Transplantation [13]. Rejection is suspected to cause atrial and ventricular arrhythmias. Therefore, arrhythmia episodes combined with a rejection grade of 2 and higher were excluded from this analysis.

	Data Collection

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
Charts were retrospectively reviewed for atrial arrhythmias and rejection episodes after hospital discharge.

	Statistics

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
Data are summarized as the mean ± standard deviation. Student's t test and Fisher's exact test were used to compare the groups. Values of p less than 0.05 were considered statistically significant.

	Results

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
The duration of ventilation and intensive care therapy and the time to hospital discharge was comparable between the groups (Table 2). Early postoperatively, there was no difference in the duration of temporary pacemaker requirement (group A, 30.8 ± 42.6 hours; group B, 19.1 ± 30.9 hours; not significant). In each group 2 patients (7%) required permanent pacemaker implantation due to bradycardia for more than 10 days postoperatively.

View larger version (17K): [in this window] [in a new window]   Fig 1. . Time of onset of atrial arrhythmia after heart transplantation.

	Comment

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

Several risk factors for the occurrence of atrial arrhythmias have been described. In nontransplant patients, large atrial size and disturbed geometry seem to precipitate atrial arrhythmias, which seem to correlate with the size of the atrium [14]. Furthermore, in the experimental setting the probability of atrial fibrillation was significantly affected by the atrial pressure [15]. Increased right atrial pressure prolongs the conduction time, thereby representing yet another risk factor causing the allotransplanted atria to fibrillate. An additional potential risk factor for development of atrial fibrillation after heart transplantation seems to be immunologic in origin. As such, the onset of atrial arrhythmias has been found to correlate with acute allograft rejection [16, 17]. All episodes of arrhythmia combined with biopsy-proven rejection were excluded from this analysis. Therefore, differences in the rejection incidence could not be the cause of the difference in the incidence of arrhythmias.

In our study, atrial arrhythmias occurred significantly less often in recipients with bicaval anastomoses compared with the standard technique. This may be explained by the significantly lower right atrial pressure in the recipients with bicaval anastomoses at 1 year after transplantation. An additional explanation may be the reduced atrial size and the preserved geometry of the right atrium by using bicaval anastomoses compared with the standard technique.

The necessity of permanent pacemaker implantation after heart transplantation ranges from 0% to 11% in the literature [18, 19], corresponding well with the incidence of 7% in our recipients. No differences could be observed between the groups in our study. This is contrary to the results of Blanche and co-workers [11], who saw significantly fewer pacemaker implantations in their patients with bicaval anastomoses (18.7% versus 0%).

In conclusion, preservation of the integrity of the right donor atrium by construction of bicaval anastomoses results in a significantly decreased late incidence of atrial flutter and fibrillation after orthotopic heart transplantation when compared with the standard technique of allograft implantation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 
Address reprint requests to Dr Brandt, Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl-Neuberg Str 1, 30625 Hannover, Germany.

	References

Top Footnotes Abstract Introduction Material and Methods Operative Technique Immunosuppression and Rejection Data Collection Statistics Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Axel Haverich Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Brandt, M. Articles by Haverich, A. Search for Related Content PubMed PubMed Citation Articles by Brandt, M. Articles by Haverich, A.